Int.J.Curr.Microbiol.App.Sci (2015) Special Issue-1: 48-58
ISSN: 2319-7706 Special Issue-1 (2015) pp. 48-58
http://www.ijcmas.com
Original Research Article
Antibiotic Resistance Pattern in Pseudomonas aeruginosa Strains Isolated at
Era s Lucknow Medical College and Hospital, Lucknow, India
Ayesha Ansari1*, S M Salman2 and Shadma Yaqoob1
1
Department of Microbiology, Era s Lucknow Medical College & Hospital, Lucknow, UP, India
2
Department of ENT, Riyadh Military Hospital, Riyadh, Saudi Arabia
*Corresponding author
ABSTRACT
Keywords
Pseudomonas
aeruginosa,
Antimicrobial
resistance,
Disk diffusion
technique,
MDR strains,
Reserve drugs
Currently antibiotic resistance in bacterial populations is one of the greatest
challenges to the effective management of infections. Pseudomonas aeruginosa is
one of the most common gram-negative micro-organism identified in clinical
specimens of admitted patients. The present study was undertaken to assess
antibiotic resistance pattern in clinical isolates of P. aeruginosa in our hospital.
This study was conducted from July 2013 to June 2014. Total of 236 P. aeruginosa
isolates were identified in various clinical specimens. The samples were selected on
the basis of their growth on MacConkey and Nutrient agar with oxidase test
positive. Antimicrobial susceptibility was performed by Kirby Bauer disc diffusion
method according to CLSI guidelines (2014). The majority of specimens from
which P. aeruginosa was isolated consisted of urine, pus and sputum. The acid
resistant penicillin such as piperacillin combination (R=16.1 %) had greater
antibacterial activity against P. aeruginosa, when compared to its monotherapy
(R=57.6%). Maximum resistance was seen against Ciprofloxacin (71.18 %)
followed by gentamicin (52.11%), ceftazidime (22.03%) and imipenem (11.01 %).
minimum resistance with amikacin and no resistance to meropenem were seen.
Infections by P. aeruginosa are life threatening and difficult to treat because of its
intrinsic resistance to various antimicrobials and its ability to acquire adaptive
resistance during a therapeutic course. Strict adherence to the concept of reserve
drugs is required to minimize irrational antibiotic usage. Therefore, amikacin and
meropenem should be used only in severe nosocomial infections, to avoid rapid
emergence of resistance.
Introduction
The Pseudomonads are a diverse bacterial
group of established and emergent pathogens
(Govan, 1998). Members of the genus are
major agents of nosocomial and community
acquired infections, being widely distributed
in the hospital environment where they are
particularly
difficult
to
eradicate.
Pseudomonas aeruginosa is the species
amongst the Pseudomonads most commonly
associated with human diseases (Hugbo and
Olurinola, 1992).
48
Int.J.Curr.Microbiol.App.Sci (2015) Special Issue-1: 48-58
Being an opportunistic human pathogen, it is
the leading cause of nosocomial infections.
It has been implicated in diverse nosocomial
infections like nosocomial pneumonias,
urinary tract infections (UTIs), skin and soft
tissue infections, in severe burns and in
infections
in
immune-compromised
individuals.
cephalosporins and quinolones (Falagas et
al., 2006).
Current study followed the definition of
MDR P. aeruginosa as stated by European
Center for Disease Prevention and Control
(ECDC) and Centre for Disease Control and
Prevention (CDC), where MDR P.
aeruginosa was defined as the one that has
acquired non susceptibility to at least one
agent in three or more categories of
antimicrobials (Magiorakos et al., 2012).
Of particular concern is that infections
caused by P. aeruginosa are frequently life
threatening and often difficult to treat, due to
the constitutive low level resistance to
several anti-microbial agents and the
multiplicity of mechanisms of resistance
(Babay, 2007). Its general resistance is due
to a combination of factors (Lambert, 2002).
It is intrinsically resistant to antimicrobial
agents, due to the low permeability of its
cell wall. It has the genetic capacity to
express a wide repertoire of resistance
mechanisms. It can become resistant through
mutations in the chromosomal genes which
regulate the resistance genes. It can acquire
additional resistance genes from other
organisms via plasmids, transposons and
bacteriophages and become resistant during
a therapeutic course. In recent years, a
considerable increase in the prevalence of
multidrug resistance (MDR) in P.
aeruginosa has been noticed; complicating
decisions on treatment with antibiotics and
its relation to high morbidity and mortality
(Ergin and Mutlu, 1999; Babay, 2007).
The periodic testing and analysis of
antibiotic resistance would enable the
physicians to detect trends in resistance
pattern to the commonly prescribed
antibiotics in a given organism.
The aim of the study was to retrospectively
analyze and determine the distribution rate
and antimicrobial resistance pattern in P.
aeruginosa among clinical specimens for a
period of 1 year.
Materials and Methods
This study was conducted at the Department
of Microbiology in a tertiary care hospital;
Era s Lucknow Medical College & Hospital,
Lucknow during July 2013 to June 2014.The
present study comprises 236 Pseudomonas
aeruginosa positive samples: swab, urine,
sputum, pus, pleural fluid, BAL, blood
samples etc. submitted for microbiological
diagnosis to the Microbiology Department.
All these samples were obtained from
various wards of hospital. The clinical data
was obtained from the respective units and
wards of the patients.
Regional variations in the antibiotic
resistance exist for different organisms,
including P. aeruginosa and this may be
related to the difference in the antibiotic
prescribing habits.
According to different studies, the term
MDR P. aeruginosa has been described as
resistance to at least three antibiotics from a
variety of antibiotic classes, mainly
aminoglycosides, penicillins, carbapenems,
Sample processing
The samples were selected on the basis of
their growth on routine MacConkey medium
which showed lactose non-fermenting pale
49
Int.J.Curr.Microbiol.App.Sci (2015) Special Issue-1: 48-58
colonies with oxidase test positive and on
Nutrient agar green pigmented (pyocyanin
production) colonies with oxidase positive.
A grape-like odor of the growing colonies
was also recognized.
panel of anti-pseudomonal antimicrobials
including:
Piperacillin (100 µ-gm)
Piperacillin - tazobactam (100/10 µ-gm)
Gentamicin (10 µ-gm)
Amikacin (30 µ-gm)
Ciprofloxacin (5 µ-gm)
Ceftazidime (30 µ-gm)
Cefepime (30 µ-gm)
Imepenem (10 µ-gm)
Meropenem(10 µ-gm).
Confirmation of Pseudomonas spp.
After obtaining the pure strains, the strains
were subjected to Gram staining (gram
negative slender rods) and biochemical
identification tests to identify Pseudomonas
spp. For this purpose samples were
inoculated in Triple Sugar Iron media (TSI),
Citratemedia, Peptone water, and Urease
media and kept in an incubator for 18 hrs at
37°C. Next day the results were noted on
TSI, Citrate media and Urease media. Part
of growth on Peptone water was subjected to
Indole test with Kovac s Reagent and part
for motility test by Hanging drop method.
Result and Discussion
A total 236 samples of P. aeruginosa were
obtained from various sources. Isolation rate
of P. aeruginosa, in our study, was
comparable with other studies.
In the present study, sex wise prevalence of
clinical isolates (Table 1) shows that
infections caused by P. aeruginosa are more
common in males (61%) compared to
females (39%). This is comparable with the
studies of Javiya et al. (2008), Jamshaid et
al. (2008), Rashid et al. (2007) and Prakash
et al. (2014) who also reported in their study
that male patients had a higher isolation rate.
A strain of Pseudomonas in the TSI medium
showed alkaline slant, no reaction in butt. It
showed negative reaction for indole test,
negative urease test and positive citrate test.
Glucose is utilized oxidatively, forming acid
only. Also Nitrate reduction test was
positive (Koneman, 2006). P. aeruginosa
ATCC 27853 strain was used as the quality
control.
Also, in our study, the age wise prevalence of
clinical isolates (Table 2) shows that most of the
patients were aged between 21 and 40 years (n =
102; 43.22%). This is comparable with the study
of Rashid et al. (2007) and Mohanasoundaram
(2011). This may be due to maximum
occupational exposure to the organism.
Antimicrobial disc: susceptibility test
Application of antibiotic discs to the
inoculated agar plates:
Antimicrobial susceptibility of all the
isolates was performed by the disc-diffusion
(Modified-Kirby-Bauer
disc
diffusion
method) and the results were interpreted
according to the latest CLSI guidelines
(2014).
In our study, maximum clinical isolates of
P. aeruginosa (Table 3; Fig. 1) were isolated
from pus/swab (53.8%), followed by urine
(16.1%) which is in line with the study of
Jamshaid et al. (2008).
All the clinical isolates and a standard strain
of Pseudomonas aeruginosa ATCC 27853
were tested for their sensitivity against a
Also, highest percentage of P. aeruginosa
infections was observed in the surgical
50
Int.J.Curr.Microbiol.App.Sci (2015) Special Issue-1: 48-58
ward, followed by pediatric ward and
medical ward. Prevalence of infection was
higher in surgical ward as maximum isolates
were isolated from pus/swab samples.
resistance was found to be 57.6% and
among the MDR isolates the resistance rate
was found to be higher (76.62%). The
ureidopenicillin combination (piperacillintazobactum), in our study, shows greater
anti-bacterial activity against P. aeruginosa
compared to its monotherapy (i.e.
piperacillin alone). Resistance rates of
piperacillin-tazobactum combination were
considerably lower (16.1%) in comparison
to piperacillin alone (57.6%) as concurrent
administration of a -lactamase inhibitor
markedly expands the spectrum of activity.
MDR strains of P. aeruginosa (Table 4; Fig.
2) were predominantly isolated from pus 40
(51.94%), sputum 13 (16.88%) followed by
urine samples 8 (10.38%). Prakash et al.
(2014) also reported a high prevalence of
MDR P. aeruginosa in clinical samples of
pus and urine, in their study.
Murase et al. (1995) in their study showed
that there is distinct difference in the
sensitivity pattern of isolates of P.
aeruginosa from specimen to specimen.
Increasing resistance to beta-lactams in P.
aeruginosa has become a serious threat,
particularly against third and fourth
generation cephalosporins. There are a lot of
molecular mechanisms to develop resistance
against these antibiotics; generation of
extended-spectrum beta-lactamases (ESBL),
by incorporation of bla genes in integrons
and inability of porin genes to enhance their
expression level and/or alteration of
antibiotic target sites (Pfeifer et al., 2010).
P. aeruginosa, in our study, showed high
resistance
rates
in
fluoroquinolones
(ciprofloxacin),
ureidopenicillin
(piperacillin) followed by gentamicin, while
minimum resistance was seen against
amikacin and no isolate was found to be
meropenem resistant (Table 5; Fig. 3).
Multidrug-resistant (MDR) P. aeruginosa is
a growing menace. Altered target sites,
bacterial efflux pumps, enzyme production
or inhibition, loss of membrane protein, etc.
are different mechanisms mediated by MDR
P. aeruginosa (Elizabeth and Vincent,
2010).
The present study showed a 32.6% (n = 77)
frequency of MDR P. aeruginosa, (Table 6;
Fig. 4) while Gill et al. (2011) reported a
22.7% incidence in Islamabad. Another
study conducted in Iran by Tavajjohi and
Moniri (2011) reported 27.6% prevalence of
MDR P. aeruginosa.
Ceftazidime and cefepime are the prescribed
anti-pseudomonal
third
and
fourth
generation cephalosporins, respectively. The
resistance to ceftazidime, in our study, was
found to be22.03% and the resistance to
cefepime was found to be 16.1%. This is
comparable to a study from Iran by
Tavajjohi and Moniri (2011) that showed
Ceftadizime resistance at 25%, but is in
contrast to high values of resistance which
were reported from Gujarat (75%) (Javiya et
al., 2008). However, among the MDR
isolates, in our study, the resistance rate was
found to be higher (Cefatzidime; 55.84% &
Cefepime; 35.06%).
The prevalence of resistance to piperacillin
in P. aeruginosa as reported by Javiya et al.
(2008) is much higher (73.21%) than that
reported in our study. Overall piperacillin
Carbapenems are considered the most
significant group of antibiotics against MDR
P. aeruginosa and the treatment of choice
against serious ESBL associated infections.
51
Int.J.Curr.Microbiol.App.Sci (2015) Special Issue-1: 48-58
However, the development of carbapenem
resistance is becoming a challenge for health
care professionals, limiting the therapeutic
options. The resistance to Carbapenems,
especially in P. aeruginosa, results from
reduced levels of drug accumulation or
increased expression of pump efflux or
production
of
metallo- -lactamases
(Kurokawa et al., 1999; Navneeth et al.,
2002; Gupta et al., 2006).
Among all the drugs, Amikacin showed the
least resistance against P. aeruginosa.
(Overall resistance - 9.32% & resistance in
MDR isolates - 23.37%). The current study
explored that anti P. aeruginosa effect of
Amikacin was higher than Gentamicin
(Overall Gentamicin resistance; 52.11% &
resistance among MDR isolates; 74%) and
this correlates with the study done by
Smitha et al. (2005), Poole (2005) and
Javiya et al. (2008). Amikacin was designed
as a poor substrate for the enzymes that
bring about inactivation by phosphorylation,
adenylation or acetylation. The high activity
of Amikacin observed in this study may be
due
to
the
presence
of
the
aminohydroxybutyryl
group,
which
generally
prevents
the
enzymatic
modification. However, some organisms
have developed enzymes that inactivate this
agent as well. Meenakumari et al. (2011), in
their study, showed a higher resistance of
56.86% to amikacin. In our study, amikacin
seems to be a promising therapy for
pseudomonal infection. Hence its use should
be restricted to severe nosocomial infections
in order to avoid rapid emergence of
resistance strains.
Prakash et al. (2014) in their study showed
22% imipenem resistance which is higher
than that reported in our study (11%). Also,
various studies have shown resistance to
Imipenem up to 31.6% (Brown and Izundu,
2004). No isolate, in our study, was found
resistant to Meropenem. Moreover, all the
26 Imipenem resistant strains, in our study,
were found resistant to the remaining antipseudomonal antibiotics, making Imipenem
resistance among the MDR isolates, 33.76%.
Fluroquinolone compounds are one of the
important antimicrobial agents that have
been used for a variety of infections.
Ciprofloxacin, the most potent agent
available in oral form for the treatment of P.
aeruginosa infections, is in particular
jeopardy. Present study showed an overall
resistance of 71.18% and a resistance of
84.4% among the MDR isolates. This is
comparable to a 3 year study from India that
reports ciprofloxacin resistance of 63.1%
(Mohanasoundaram, 2011). Tam et al.
(2010) in their study claimed 100%
resistance against Ciprofloxacin. High
degree of resistance is probably because of
the irrational approach of the clinicians of
putting patients on quinolones straightway
without going for antibiotic sensitivity.
Because of the increasing resistance to
fluoroquinolones in many hospitals, its
empirical usage is either banned or
restricted, to bring the developing resistance
rates under control.
Our study thus indicated amikacin and
meropenem as an efficient treatment of
choice against MDR P. aeruginosa among
all the tested antibiotics.
Also it brings to light that the clinical
isolates of P. aeruginosa are becoming
increasingly resistant to commonly used
antibiotics and gaining more and more
resistance to newer antibiotics. The
antimicrobial agents are losing their efficacy
because of the spread of multi-drug resistant
strains due to indiscriminate use of
antibiotics, lack of awareness, patient noncompliance and non-availability of antimicrobial testing facilities.
52
Int.J.Curr.Microbiol.App.Sci (2015) Special Issue-1: 48-58
Antibacterial research is not sufficient to
keep pace with the clinical challenges of
MDR bacterial crises. Lack of new drug
pipelines and other issues are leaving
disastrous consequences on the health of the
community. To overcome such issues, new
therapeutic agents with maximum efficacy,
lesser toxicity and cost effective in nature
are urgently needed.
surveillance should be done periodically to
monitor the current susceptibility patterns in
local hospitals, to keep a tab on the
development and spread of MDR strains.
An effective national and state level
antibiotic policy and draft guidelines should
be introduced to preserve the effectiveness
of antibiotics for better patient management.
It is the need of the time that antibiotic
policies should be formulated and
implemented to resist and overcome this
emerging problem. Every effort should be
made to prevent the spread of multi-drug
resistant strains.
So in the present time, there is a need to
emphasize rational use of antibiotics and
strict adherence to the concept of reserve
drugs to minimize the misuse of available
antimicrobials.
Rigorous
antimicrobial
Sex
Male
Female
Total
AGE (YEARS)
0 20
21 40
41 60
> 60
TOTAL
Table.1 Sex wise distribution of cases
Total no
Percentage (%)
144
61.1
92
38.9
236
100
Table.2 Age distribution of cases
NO. OF ISOLATES
PERCENTAGE (%)
85
36.01
102
43.22
36
15.25
13
5.5
236
100
Table.3 Isolation of Pseudomonas aeruginosa from different clinical samples
NATURE OF SAMPLE
NO. OF SAMPLE
PERCENTAGE (%)
127
53.8
PUS
14
5.9
SPUTUM
10
4.2
BAL
20
8.4
SWAB
38
16.1
URINE
16
6.7
CATHETER TIP
10
4.2
BLOOD CULTURE
1
0.4
CSF
53
Int.J.Curr.Microbiol.App.Sci (2015) Special Issue-1: 48-58
Table.4 Isolation of MDR Pseudomonas aeruginosa from different clinical samples
Nature of sample
Pus
Sputum
Bal
Swab
Urine
Catheter tip
Blood culture
Csf
No. of sample
40
13
4
7
8
2
3
0
Percentage (%)
51.94
16.88
5.19
9.09
10.38
2.59
3.89
0
Table.5 Antibiotic resistance of Pseudomonas aeruginosa isolated
from different clinical samples
Antibiotic
No. of Isolates Resistant
% Resistance
Piperacillin
Piperacillin - tazobactam
136
38
57.6
16.1
Gentamicin
123
52.11
Amikacin
22
9.32
Ciprofloxacin
168
71.18
Ceftazidime
52
22.03
Cefepime
38
16.1
Imipenem
26
11.01
Meropenem
0
0
Table.6 Antibiotic resistance of MDR Pseudomonas aeruginosa (n= 77) isolated
from different clinical samples
Antibiotic
Piperacillin
Piperacillin tazobactam
Gentamicin
Amikacin
Ciprofloxacin
Ceftazidime
Cefepime
Imipenem
Meropenem
No. of Isolates Resistant
59
30
57
18
65
43
27
26
0
54
% Resistance
76.62
38.9
74.02
23.37
84.4
55.84
35.06
33.76
0
Int.J.Curr.Microbiol.App.Sci (2015) Special Issue-1: 48-58
Fig.1 Sample-wise distribution of P. aeruginosa isolates (overall)
Fig.2 Sample-wise distribution of P. aeruginosa isolates (MDR)
55
Int.J.Curr.Microbiol.App.Sci (2015) Special Issue-1: 48-58
Fig.3 Antibiotic resistance pattern of P. aeruginosa isolates (overall)
Fig.4 Antibiotic resistance pattern of P. aeruginosa isolates (MDR)
56
Int.J.Curr.Microbiol.App.Sci (2015) Special Issue-1: 48-58
Govan, J.R.W. 1998. Pseudomonads and
nonfermenters. In: Greenwood, D., R.
C. B. Slack and Peutherer, J. F. (Ed.),
Medical Microbiology. Churchill
Livingstone, Edinburgh, Pp. 284 289.
Gupta, E., Mohanty, S., Sood, S., Dhawan,
B., Das, B.K., Kapil, A. 2006.
Emerging resistance to Carbapenems
in atertiary care hospital in North
India. Indian J. Med. Res., 124: 95 98.
Hugbo, P.G., Olurinola, P.F. 1992.
Resistance
of
Pseudomonas
aeruginosa to antimicrobial agents:
Implications
in
medicine
and
pharmacy. Niger. J. Pharma. Sci., 4:
1 10.
Jamshaid, A.K., Zafar, I., Saeed, U.R.,
Farzana, K., Abbas, K. 2008.
Prevalence and resistance patterns of
Pseudomonas aeruginosa against
various antibiotics. Pak. J. Pharm.
Sci., 21(3): 311 315.
Javiya, V.A., Ghatak, S.B., Patel, K.R.,
Patel,
J.A.
2008.
Antibiotic
susceptibility patterns of Pseudomonas
aeruginosa at a tertiary care hospital in
Gujarat, India. Indian J. Pharmacol.,
40: 230 234.
Koneman. 2006. The non-fermentative
gram-negative Bacilli. In: Koneman s
color atlas and textbook of diagnostic
microbiology, Sixth edn., Williams &
Wilkins, Lippincott. Pp. 303 391.
Kurokawa, H., Yagi, T., Shibata, N.,
Shibayama, K., Arakawa, Y. 1999.
Worldwide
proliferation
of
Carbapenem resistant gram negative
bacteria. Lancet, 354: 955.
Lambert, P. A. 2002. Mechanisms of
antibiotic resistance in Pseudomonas
aeruginosa. J. R. Soc. Med., 95 (suppl.
41): 22 26.
Magiorakos, A.P., Srinivasan, A., Carey,
R.B., Carmeli, Y., Falagas, M.E.,
Giske, C.G. 2012. Multidrug-resistant,
extensively
drug-resistant
and
Acknowledgement
We would like to thank all the technical staff
of the Department of Microbiology for their
invaluable support.
References
Babay,
H.A.H.
2007.Antimicrobial
Resistance among Clinical Isolates of
Pseudomonas
aeruginosa
from
patients in a Teaching Hospital,
Riyadh, Saudi Arabia, 2001-2005. Jpn.
J. Infect. Dis., 60: 123 125.
Brown, P.D., Izundu, A. 2004. Antibiotic
resistance in clinical isolates of
Pseudomonas aeruginosa in Jamaica.
Rev. Panam. Salud Publica., 16: 125
130.
CLSI. 2014. Performance standards for
antimicrobial susceptibility testing;
twenty-fourth
informational
supplement. CLSI document M100S24. Clinical & Laboratory Standards
Institute, Wayne, PA.
Elizabeth, B.H., Vincent, H.T. 2010. Impact
of multi-drug resistant Pseudomonas
aeruginosa infection on patient
outcomes. Expert Rev. Pharmacoecon.
Outcomes Res., 10(4): 441 451.
Ergin, C., Mutlu, G. 1999. Clinical
distribution and antibiotic resistance of
Pseudomonas species. East. J. Med.,
4(2): 65 69.
Falagas, M.E., Koletsi, P.K., Bliziotis, I.A.
2006. The diversity of definitions of
multi-drug resistant (MDR) and pan
drug-resistant (PDR) Acinetobacter
baumannii
and
Pseudomonas
aeruginosa. J. Med. Microbiol., 55:
1619 1629.
Gill, M.M., Usman, J., Kaleem, F., Hassan,
A., Khalid, A., Anjum, R., Fahim, Q.
2011. Frequency and antibiogram of
Multi-drug resistant Pseudomonas
aeruginosa. J. Coll. Physicians Surg.
Pak., 21(9): 531 534.
57
Int.J.Curr.Microbiol.App.Sci (2015) Special Issue-1: 48-58
pandrug-resistant
bacteria:
an
international expert proposal for
interim standard definitions for
acquired resistance. Clin. Microbiol.
Infect., 18(3): 268 281.
Meenakumari, S., Verma, S., Absar, A.,
Chaudhary, A. 2011. Antimicrobial
susceptibility pattern of clinical
isolates of Pseudomonas aeruginosain
an Indian cardiac hospital. Int. J. Eng.
Sci. Technol., 3(9): 7117 7124.
Mohanasoundaram,
K.M.
2011.
Antimicrobial
resistance
in
Pseudomonas aeruginosa. J. Clin.
Diagn. Res., 5(3): 491 494.
Murase, M., Miyamoto, H., Handa, T.,
Sahaki, S., Takenchi. 1995. Activity of
antipseudomonal agent against clinical
isolates of Pseudomonas aeruginosa.
Jpn. J. Antibiot., 48(10): 1581 1589.
Navneeth, B.V., Sridaran, D., Sahay, D.,
Belwadi, M.R. 2002. A preliminary
study
on
metallo
-lactamase
producing Pseudomonas aeruginosa in
hospitalized patients. Indian J. Med.
Res., 116: 264 267.
Pfeifer, Y., Cullik, A., Witte, W. 2010.
Resistance to cephalosporins and
carbapenems
in
Gram-negative
bacterial pathogens. Int. J. Med.
Microbiol., 300(6): 371 379.
Poole K. 2005. Aminoglycosides resistance
in
Pseudomonas
aeruginosa.
Antimicrob. Agents Chem., 49: 479
487.
Prakash, V., Mishra, P.P., Premi, H.K.,
Walia, A., Dhawan, S., Kumar, A.
2014.
Increasing
incidence
of
multidrug resistant Pseudomonas
aeruginosa in in-patients of a tertiary
care hospital. Int. J. Res. Med. Sci., 2:
1302 1306.
Rashid, A., Chowdhury, A., Sufi, H.Z.R.,
Shahin, A.B., Naima, M. 2007.
Infections by Pseudomonas and
antibiotic resistance pattern of the
isolates from Dhaka Medical college
Hospital.
Bangladesh
J.
Med.
Microbiol., 01(02): 48 51.
Smitha, S., Lalitha, P., Prajna, V.N.,
Srinivasan, M. 2005. Susceptibility
trends of Pseudomonas species from
corneal ulcers. Indian J. Med.
Microbiol., 23: 168 171.
Tam, V.H., Chang, K.T., Abdelraouf, K.,
Brioso, C.G., Ameka, M., McCaskey,
L.A. 2010. Prevalence, mechanism and
susceptibility of multi drug resistant
bloodstream isolates of Pseudomonas
aeruginosa.
Antimicrob.
Agents
Chemother., 54: 1160 1164.
Tavajjohi, Z., Moniri, R. 2011. Detection of
ESBLs and MDR in Pseudomonas
aeruginosain a tertiary-care teaching
hospital.Iran. J. Clin. Infect. Dis., 6(1):
18 23.
58